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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD FORM A: UNDERGROUND STORAGE TANK PROGRAM �a SITE G FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION COMPLETE THIS FORM FOR EACH FACILITY/SITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE Z 1. FACILITY/SITE INFORMATION & ADDRESS - (MUST BE COMPLETED) FACILITY/SITE NAME l'Z3(/_U?. CARE OF ADDRESS INFORMATION it e ✓�.., i+ ADDRESS NEAREST CRS STREET, O PAIUNERSHIPCl STATE /J 0�� LOX AGROTXG90 TLi ( [I lmmouu [1 CUM AGENCY CITY NAMENy, STATE ZIP CO SITE PHONE If,WITH AREA CODE 7&vy CA ' TYPE OF BUSINESS. ❑ P DISTRIBUTOR ❑ 4 PROCESSOR ✓Box it DIAN EPA ID n F of TANK's 5 OTHER RESERV TION or El THIS SITE ❑ I GAS STATION ❑ 3 FARM ❑ TRUST LANDS EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) DAYS'. NAME ILAST,FIRST) PHONE N WITH AREA CODE DAYS: NAME(LAST.FIRST) PHONE 0 WITH AREA CODE NIGHTS. NAME(LAST.FIRST) PHONE M WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box loindicate 0 PARTNERSHIP 0 STATE-AGENCY 0 CORPORATION D LOCAL-AGENCY 0 FEDERALAGENCY D INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE 4,WITH AREA CODE Ill. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) NAME CARE OF ADDRESS INFORMATION MAILING or STREET ADDRESS ✓Box to,nd,cale 0 PARTNERSHIP 0 STATE-AGENCY D CORPORATION Cl LOCAL-AGENCY ❑ FEDERAL-AGENCY 0 INDIVIDUAL 0 COUNTY-AGENCY CITY NAME STATE ZIP CODE PHONE I,W(TH AREA CODE IV. LEGAL NOTIFICATION AND BILLING ADDRESS CHECK ONE(1)BOX INDICATING WHICH ABOVE ADD=$$SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: 1. ❑ IL ❑ 111. ❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY R JURISDICTION E AGENCY M FACILITY ID R B of TANKS N SITE `- D7 = = I I I 11 -4-07-1 06 CURRENT LOCAL AGENCY FACILI ION APPROVED BY NAME PHONE F WITH AREA CODE EtPERMIT PERMIT NUMBER PPROVAL DATE PERMIT EXPIRATION DATELOCA710NDCODE CENSUS TRl1SUPERVISOR-DI ICT CODE BUSINESS PLAN FILED DATE FILED33 2 ZJ YES NO CHECK F PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT F BY: /JI THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS ISA CHANGE OF SITE INFORMATION ONLY. FORM A(3-2-&8)